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10 May 2012
Classification of Medicare Benefits Schedule (MBS) item 42738 (intravitreal injection) in the Private Health Insurance (Benefit Requirements) Rules 2011
Item 42738 was introduced on the MBS from 1 March 2012 and was initially classified in the Private Health Insurance (Benefit Requirements) Rules 2011
(the Rules) as a Type C procedure. This classification was based on medical advice and MBS data which showed that the vast majority of this service was provided outside of hospital.
A Type C procedure normally does not require hospital treatment however if a patient’s clinical or special circumstances require the procedure to be performed in hospital, insurers are required to pay the relevant hospital accommodation benefit when the medical practitioner rendering the procedure provides the appropriate certification. In practice this requires completion of Part 4 of the National Private Patient Hospital Claim Form. The certification should provide justification that it would be contrary to accepted medical practice to provide the procedure to the patient unless it was provided as part of hospital treatment.
Since the classification of item 42738 as Type C in the Rules, concerns have been raised that patients may be adversely affected by the classification. Consequently, the Department reclassified the item as a Type B procedure in the Rules, effective 21 April 2012. A Type B procedure is one that normally requires same-day hospital accommodation. This change was made pending further consultation with consumer representatives, medical groups and private health insurers.
The Department seeks Private Health Insurers’ views on the effect of item 42738 being classified in the Rules as a Type C procedure, and specifically what effect this would have on patients and whether there is scope to ameliorate any detrimental impact on patients.
It should be noted that item 42738 is a ‘hospital-substitute’ service as described in Part 3 Rule 10 of the Private Health Insurance (Health Insurance Business) Rules 2010
. This means that under the Rule, Private Health Insurers can provide benefits for this service when performed outside of hospital. Insurers may wish to comment on whether this arrangement provides any benefit in practice in this instance.
It would be appreciated if you could provide written comments and views on the classification of item 42738 by 8 June 2012.
If you require further information please telephone: (02) 6289 9853/24 hr answering machine or email the enquiry to Private Health Insurance Branch
For more information visit 2012 Private Health Insurance (PHI) Circulars
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